Specialists not only have a duty of care for patients but also for their trainees. This was the message from Melbourne-based medical oncologist Dr Ranjana Srivastava in a session on mentoring at ASCO 2019.
In her presentation, Dr Srivastava said it was wrong to think that the current generation of trainees are ‘softer’ or having an easier time than their predecessors. She presented figures showing that hospital workloads have increased substantially in the last decade, and trainees now face a much more complex and competitive environment, with extremely high expectations in many areas compared to what their seniors faced during in training. She cited the example of dealing with a vastly higher number of phone calls and requests for help due to availability of new treatments such as immunotherapy. Where in the past a trainee might have expected to get some sleep while on call, this was no longer the case.
Therefore it is more important than ever for mentors and supervisors to help trainees deal with the issues they face in the new “exciting but confusing” landscape of oncology, she said.
Her ‘prescription’ for oncology mentors included the following tips:
1. Exchange knowledge, not dispense it
“Supervisors don’t know everything, and that’s OK. Our interests don’t have to completely align with our trainees, but what’s really important is having shared interests, values and exploring the goals of our trainees. And this means the ability for both parties to learn from each other. My supervisor once said to me: ‘Sometimes the hardest thing to do in oncology is know when to do nothing.’ And that is a great example of pairing the wisdom of experience with the bookish knowledge that fellows have. How do we do this in a practical setting? I think by reviewing cases post-clinic is a really practical of helping our trainees. And when they are seeing many patients in consults, especially with the heavy burden of time, it’s so tempting to tell them what to do. Instead I think we need to step back and say – what would you do? This is how we make trainees into empowered oncologists.
And something small but really important is outright acknowledgement when somebody else does it better. In a long career I have a few examples of this, such as when as a very junior fellow I went to intensive care to see a patient who’d had every test under the sun and we didn’t know what was going on. Almost with embarrassment I said to my attending [oncologist] that [the patient] could have a PE, and he said we should get a CT pulmonary angiography. Lo and behold this showed a large central embolus that required emergency thrombolysis, and the patient lived. That was great but the reason I remembered this incident was that the next day the attending oncologist pulled me aside on the ward round and said ‘Great job, well done, I would have missed that.’ Twenty years on I still remember that – but how many times does that happen? So it’s really important to acknowledge our trainees when they do something good.”
2. Help trainees distinguish the difference between discovering a career and imitating our own.
“Imitation may be the sincerest form of flattery, but I think we need to understand the motivations, goals and personal circumstances of our trainees. And empathising as much with the road not taken as the one taken. That means using our learned experience to offer advice about the choices they have made, and the consequences of those choices. Because we can look back and look forward. It also means a very generous sharing of contacts and connections and our career supports and life supports, because we know that without that we are all bereft. Also being unafraid to share personal vulnerability. That may make some people uncomfortable but I think it’s very important to show our trainees some unedited version s of it because we know we are not just our CVs. We all have flaws and it’s important for our trainees to see what they are.
3. We should debrief after critical incidents.
I know that every hospital and institution has a de-briefing program but I think we do it poorly. And when I reflect on why this is I think every oncologist who has been in the game for a number of years has seen one of everything. We have seen the young patient who came in and crashed and died before we cold do anything. We have been in difficult family meetings. We have been to court at some point. We have had complaints written about us. And we deal with all manner of difficult patients. Out trainees still have a limited catalogue of such experiences but they have the same emotions. So it’s very important when trainees are navigating new and challenging experiences that we understand that this requires quite an advanced form of thinking and reflection and that we need to co-operate with trainees and show them how to navigate this. And that means pro-actively anticipating emotions, being honest about our own reactions. In other words, we need to provide the same holistic care to our trainees and their needs that we strive to provide to our patients.
4. Harassment and burnout in medicine are real and our responsibility to address
“In a beyondblue survey, oncologists were found to be the most psychologically distressed of all medical professionals. And we know that despite showing higher rates of resilience, doctors have twice the rates of distress and self harm as the general population and other professions. Burnout is not unique to oncology but I think the life and death balance we always hold in our hands makes oncologists particularly prone to burnout. And interestingly, burnout rates are similar in trainees and experienced oncologists. So I think there is a lesson for those of us who think you need to put in the hours and years before you can complain about burnout.
5. Foster a better culture
“While institution-level interventions are ideal, we can leverage our our seniority as mentors and supervisors to advocate for change. In our hospital we do Schwartz Rounds, which are multidisciplinary. Monthly breakfasts, scheduled de-briefs – it doesn’t matter how you do it so long as you find something that works at your level. But I think it also takes an individual open-ness to believing the figures (on the increased work and stress burden on current trainees) and not dismissing them as a ‘first world problem’. I think this takes a personal commitment to create a respectful working environment and good after hours call support environment, etc.
It’s also important to defend our trainees against unacceptable conduct. As much as we would like to deny this, we know that there is a lot of unacceptable conduct that still continues against trainees. This is a difficult one because it’s always nice to step away from confrontation. A classic scenario would be when. Trainee is feeling harassed or has a problem with another attending [oncologist] – and you think what should I do? Should I speak to that oncologist or if I ignore it will it go away? But generally those things don’t go away. So part of empowering trainees is helping them to work through these issues: is it that they are being sensitive to something that is appropriate criticism – or does it constitute harassment? And then to take appropriate action. And the last thing is the most important – helping them through the consequences. Because we all know that one of the main reasons that people don’t bring complaints forward is because they are worried about the consequences, especially to their own career. We are all prone to thinking that other people need reforming, not us.”
6. You can’t be what you can’t see
“It’s important for trainees to have supervisors who are good role models. This means a capacity for introspection and a capacity to change. Listening to feedback, sensing what’s going on as a supervisor and being willing to change and to adapt. Also acting at all times with integrity. My favourite definition of this is what you do when nobody else is looking. And in oncology there are many opportunities for acting with integrity. We have heard that oncology trainees are so busy seeing 50 patients in clinic that they don’t have time to see mentors. So our job is to elevate the significance of mentors in trainees lives and make it possible for them to engage with us. Believe in the power of pastoral care. This is not just for ourselves and patients but also for our trainees. Because good mentors make better trainees into better doctors, more satisfied patients and better society – which is why we are all here.”
Dr Ranjana Srivastava concluded the presentation with a quote from former British Prime Minister Benjamin Disraeli: “The greatest good you can do for another is not just to share your riches but to reveal to him his own.”